Health Insurance & "Prior Authorization"

January 12, 2019 1:26 AM

I need to get a new-ish, specialized surgical procedure and am having trouble getting prior authorization - BCBS reps say it's "waived."

I've spoken to three reps on the phone now, and all of them say that for the coding my (in-network) surgeon gave me, they are unable to provide any sort of written form indicating ahead of time whether or not they will cover my (expensive and needed) surgery. ("Prior auth waived") Meanwhile, the doctor can't schedule me without my signed financial consent form stating I'll pay out of pocket if BCBS doesn't.

I feel like this is some sort of a guessing game or a gamble - will they or won' they? The surgeon's office says that for previous patients on similar plans, it has varied - about 50/50 - but no real way to predict, apparently it depends on who is processing the claims once they are filed. The reps on the phone tell me it 'should be' covered but that they can't guarantee anything until the surgeon submits the claim.

I'm wondering how else I can advocate for myself in this situation. I'm pretty low on 'spoons' (energy, for those with chronic illness) for making more calls but my condition also worsens progressively each month that I don't get the operation.

Any patients, health advocates, nurse case workers, or insurance reps here have ideas?

posted by CancerSucks to Health & Fitness (7 answers total)

I'm puzzled by the language here. "Prior authorization waived" usually means just that they are not requiring that you get permission in advance to have the procedure. It is not believable--or acceptable--that they can't tell you whether a procedure will be covered or not in advance. Either a procedure is covered all the time when ordered by an appropriate provider, or it's covered when you establish medical necessity to their satisfaction through a prior authorization mechanism, or it's not covered. There's no case-by-case after the fact determinations, unless the procedure was done on an emergency basis.

Two routes: your insurance should have an ombudsperson, and your state should have an insurance commission or division of its attorney general which may provide assistance to consumers in dealing with their insurance companies. If you're still in California, that's the Department of Insurance.

Best of luck to you. This sounds exhausting.
posted by praemunire at 1:45 AM on January 12, 2019 [6 favorites]

It is not believable--or acceptable--that they can't tell you whether a procedure will be covered or not in advance. Either a procedure is covered all the time when ordered by an appropriate provider, or it's covered when you establish medical necessity to their satisfaction through a prior authorization mechanism, or it's not covered.

It's worth noting that the letter they send you saying you've received prior authorization inevitably contains language saying it is not a guarantee the claim will be paid. In my experience, insurance coverage will never state whether something will be covered until presented with the actual claim--they'll say something is generally covered or should be covered, but not that it will be in your particular case.
posted by hoyland at 4:01 AM on January 12, 2019 [4 favorites]

And every hospital has a form with some language in the US that you'll have to sign to agree to pay of the insurance doesn't. It is standard. You will sign it regardless even if you have a prior auth.
posted by AlexiaSky at 4:45 AM on January 12, 2019

BC and BS are assholes. I've had them tell me "no pre-auth needed" and what wasn't said was "no pre-auth is needed because we have no intention of paying for this". Tell them that you want a "pre-determination." You or your doc gives them the codes that will be billed (CPT) and the diagnosis codes that will be billed (ICD-10) and BCBS should be able to run a mock claim to see the likelihood of your surgery being paid. The reason your doc has a 50/50 pay rate with BCBS is everyone has different levels of coverage. Your plan may allow all the CPT codes, someone else with BCBS may have a plan that only allows some of the codes. It's impossible to know what will happen with you unless they run a pre-determination with your specific information.

rant/ Healthcare in this country is broken. I am so fucking lucky and privileged that I even have healthcare insurance and it's absolutely heartbreaking that I consider myself lucky that I have a basic human right./rant
posted by dogmom at 6:29 AM on January 12, 2019 [23 favorites]

I think the surgeon's office is giving you some unhelpful information here and should ideally be more helpful about HOW to maximize the chances of getting the claim paid instead of acting like insurance is at the whim of a fickle god.

Getting insurance to pay for things requires jumping through hoops. Hoop 1 is prior authorization. If it is waived, then you have jumped through that hoop. The "should be covered" language is as close as certainty as you are going to get before they see the claim. They could tell you now "yes, will be covered" and then your surgeon submits a claim for 78 hours of OR time and rhinestone-encrusted scalpels, and they don't want to pay for that. So, "should be covered" isn't a red flag or anything to be worried about.

It is possible that they will deny the claim after your surgery (it's not likely with a waived pre auth, just possible). If this happens, don't freak out, just ask BCBS about the appeals process. They may need your surgeon to write a letter or supply additional evidence of medical necessity. This where I feel your surgeon's office could have been more helpful - instead of saying, "eh - 50/50 chance it'll be covered" they could have talked to you about how they work through the appeals process with patients.

If you wanted to make additional calls to set your mind at ease, my next call would be to the surgeon's office to ask how they assist patients in handling appeals for this procedure if they receive an initial denial. And in the UNLIKELY event this happens, frame it in your mind that way - initial, temporary, interim, resolvable. Another insurance hoop.
posted by jeoc at 6:38 AM on January 12, 2019 [1 favorite]

Every state has an insurance regulating unit, it will be under the Attorney General's website. They may be able to assist you with getting it sorted out.
posted by theora55 at 9:13 AM on January 12, 2019 [1 favorite]

It's worth noting that the letter they send you saying you've received prior authorization inevitably contains language saying it is not a guarantee the claim will be paid.

Good point, but that is intended to cover the rhinestone scalpel scenario outlined above. That kind of letter, post a pre-determination, should be enough for OP, but it sounds like the reps are making it extremely confusing for OP.
posted by praemunire at 11:35 AM on January 12, 2019